30004 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 30004
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
1 d 3S" a Pa"V^ii-s o Cr) � 3 7 9�
OW S A e U �6+ P1198tS�-6D00 SG A� Revel LIC NO: r
NIC CONTROL#
A HITA MNGINEER: LIC NO: ADDRESS: 1 ❑
Uher. /9rc ' '{sets $O'�SO ee�ufa i7"o .2 4,0
CONTACT. PHONE: BUILDING PERMIT INFO
O#e Cvo er 1/0 815-6 06/ ❑ Consultant Fees Paid by Appliunt(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 herebyffmn Na I am become nrmcr provls ,,..homer 9 Rommeneing JOB DESCRIPTIONI�Iuu�O with Sectioh](If,O)iaf Division TdNe Bocincss roil Professfcoions Cute,and mylicense is PERMIT ISSUANCE �+
FRESIDENTIAL
� full fame and effect I:pWL ❑KITCHEN REMODEL
�U�jin
Class Coamc APPLIANCES—RESIDENTIAL CADDITION. [I PLUMBING R&PIPE
a Dam TSD17CL
ARCHITECT'S DIiCLARATION DZAULT1-UNIT ❑STRUCNRAI.
I ZFpn,z� lundersland my plans shall he used us public recalls PANELS MODIFICATION
pz_Q UPTO200AMPS (3 INTERIOR El CHIMNEY REPAIR
r4tw Licensed Professional 2UI-IIMYJ AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION 0y1;µlUfI0AMp5 - C BATH REMODEUREPAIR 0DEMOLITION
�
p, G 1 thereby affiant that I oro exempt from the Cmao nor,License Law for the
sec 3 U following reason.(Section 703 L5,Business and Protestant Cale:Any city or county SIGNS ELECTRICAL
❑OTHER
which requires a Permit to construct,alma improve,demnlish,or repair any structure
prianoibis...a..also requirea the updicud for such perma 1.file a signedstmement SPECIAL CIRCUI I/MISC.
ythat he is licensed pursuant to the provisions of the Contrechtrs License Law(Chapter 9 1 '
00 (commencing with Section]000)M Division 3 of the Busi ness and Protestors Code)or TEMP.MITER OR POLE INST. COMMERCIAL:
a c IY that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0,W BLU('JADDITIOtN1�` ❑DEMOLITION
�y Section 7031.5 by anyappliwm fora permitsuhjvid the applicant too civil penalty of POWER DEVICES �yy6,wTu o ❑FOOD SERVICE
F z} not more than five hundred dollars($500). IMPROVEMENT '
< 1I,as owner affair property,or myemployees with wages as Neirsole compensation, SWIMMING POOL ELECTRIC
�qo will du the work,and the structure is not intended or offered for sale(Sec.7044,Dusiness dc: ❑OTHER `w
W m and Professions CoThe Contractors License Law docs not apply to an owner of OUTLETS—SWITCHES—FIXTURES
6 3^ progeny who huiM,or improves thereon,and who dces m n work himself ear through
his own employees,the
provided that such improvements is
are not intended or offered for NEW RESIDENTIAL IiLECTN SQ FT,
sale.IL however.the building or impravenmmis salt within one yeaof complminn,the �1�s/+ SQ.PT.FLOOR AREA SISQ.FT.
poenbuilder will have the burden of prising that he did not build or Improve for par- D W V � / 2
seafade.). G 7</-V 7
I,m owner of Ne property,am exclusively contracting will licenced contractors us I p SF TOTAL:
construct the project(Sec.7114,Business and Perfusions Cod,,)ne Contractor's Li- �y 2
cause Law does not apply to an owner of property who builds or improves[he..,and QTY. PLUMBING PERMIT FEE d si a I c
who contracts for such projects with a con meour(s)licensed pursuansro the Comtuctoee
License Law. PERMIT ISSUANCE
❑ Lamexemptunder Sec. ,B&PCforthisreason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Owner Date /, yys664
WONKF.RSCAPE Ndury on DBCLARA'HON BACK FLOW PROTECT.DEVICE /
1 hand will
micapenahy ofperjuryaneof Nefollowing dorkers ns: ✓
[have and will muinminu CeniOcme of Cansenuosel Ginsurc forWaker's Compen- DRAINS—FLOOft,ftOOP,AREA.GOND. STORIES TYPE CONSTRUCTION
anion ax fur by Section 000 of the LuMr Cokc,for the petlonnancc of the
work far whichhick this Permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation of the w Insurance,h required by Section
of the and work fnu which Nis permitisissued GAS—EA.SYSTEM-I INC.JOUTLETS OCC.GROUP APN
Ca Worker's Compensation Inaumnce.artierand policy number are: -
Camier. Policy No.: O'AS—EA.SYS'T'EM-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GNLASFJINDU$TRL WASTE.INTERCEPTOR
BUILDING DIVISION(FES
leas.)
This section need not hecompleteJ ifthe permit is forone hundred dollars($101) GREASETRAP PLANCHECK FEE Jb5331"
nr
I certify Net in the Performance offhe work for which this Permit is issued,l shall SHWER—SAN]TARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Wurkers'Comperr ENERGY FEE
z section Uwa o1 Calil'amia.Duce WATER HEATER WIVENT/ELECI'R
0 Applicant GRADING FUE
y NOTICE TO APPLICANT:IL a0er necking this Certificate of Exemption,you should WATER SYSTEM/TREATING
SOILS FEF: bq
F-'
become suompm the WmkeroCsions or this Permit
of tae Labra Code,you most ).la
I Lail � forthwith comply with such provisions or permit shall Mdeemed revoked. WATER SERVICE
aQ
i
z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID Dae Receipt p
U QIherehy affirm that there ixuconstructinn lending agency lar the performance of
tae wmk for which this permit is issued(Sec.3097,Civ.CJ
U. F' Lenders Name TOTAL:
Lender's AddressTOTAL:
Lyy� I certify that I have read this application and some that above information is /�� BUILDING FEE
F Val correct.I agree to comply with all city and county ordinances and state laws relating In QTY. MECHANICAL PERMIT FEE - r
SEISMIC FEE ss--
V.Z-s abovengcotioned construction, hereby aahodxreoses, Lives of this city us enter upon the 3#
above-mentioned for inspection keep es. PERMIT ISSUANCE ,alt /
(We)agree to save,indemnify and keep harmless the City of Cupeninn against ELECTRIC FEE d(..44
lisbilities,judgm ats,cosuand expenses which mayinany waynecme agmnstsad City ALTER OR ADD TO MECH.
in
i
in consequence ofthe granting of this period. PLUMBING FEE -2
APPLICANT U'DERSTANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,1KK1 CFM) �i
SOURCE REG
TIONS MECHANICALFEE /=Z
AIR HANDLING UNIT(OVER IO,WOCFM) CONSTRUCTION TAX S,qj3.q40
Si Si gnmK.&Applicam/Cumractio' Anne EXHAUST HOOD OVMUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,end Ne Health and Safety
Cede,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
El Yes E]No PAID
VENTILATION PAN(SINGLE RHSID) Dam Receipt#
Will the applicant or future building nccupam use equipment or devices which
emit hazardous an contaminants es defined by the Bay Area Air Quality Management BOILER—COMP CHROR 100,010 BTU(
District? TOTAL: �l MAQG
❑Yea ❑No BOILER—COMP(OVER 100,000 BTU)
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
femme Health&Safety Cade,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.IT.
building dos not currently lave a tenant.Nat it is my mspxmsibility to notify Nc occupant
of Ne raquimmenb which must he and prior to issuance of a Cenhicate of Occupancy. /1 n `
Owner oraahorized agent Dae TOTAL: I �SUr, ISSUED HY: -
OFFICE